Telemedicine: the doctor will FaceTime you now
Today, nearly 1 dollar in 5 in the US is spent on healthcare (17.9% of GDP in 2019). The average in rich countries is less than 1 in 10 (9%). These are figures from 2019, before the COVID pandemic caused up to 41% of people to delay or cancel healthcare treatment.
The US system is particularly ineffective and costly. Based on almost all measures (except cancer treatment), US healthcare provides worse results (life expectancy, infant mortality, obesity, etc.), covers fewer people (11% of people don’t have health insurance), and spends 5.5x more on administrative overhead. If the US were to adopt a similar system to other wealthy countries, it could save nearly 9 points of GDP (and cover 100% of its population). If those savings were a country that would make it the 9th largest economy in the world (just ahead of Brazil). Given that healthcare costs have been rising at 2–3x the rate of inflation and rich country populations are aging, our current model will not scale (even for other countries whose costs are not as out of control as those in the US).
In 1901, average life expectancy for men was 47 (50 for women) and most people died of causes that are easily avoidable at present. The top 3 were diarrhea, tuberculosis, and pneumonia. Today, most people die of chronic diseases (treatable, but not curable). 6 in 10 adults in the US have a chronic disease (4 in 10 have 2 or more). The #1 killer is cardiovascular disease. For 50% of people afflicted with the disease, the first symptom is death.
The issue is that we don’t have a healthcare system, but a sickcare system (we spend dramatically more on treatment than on prevention). For example, 25% of all Medicare (health insurance for the elderly) is spent on people during their last year of life.
In 2015, I was part of a team at Nokia that was creating a business unit focused on digital technology for healthcare. We assembled an illustrious panel of doctors from the top medical providers in Silicon Valley, including Kaiser Permanente, UCSF, and Singularity University. We asked these experts what people could do to deal with the growing issue of chronic diseases. Echoing the counsel for moderation provided by the Greek philosopher Hesiod 2,700 years earlier they said: “eat well, sleep well, and stay active.”
We need to evolve from a system of “intervention when ill” to a system of continuous monitoring and encouragement of healthy habits. Digital technologies can help to create such systems at scale. Activity trackers such as Fitbit and Jawbone (and now Apple Watch, or even your mobile phone) can report on daily activity and heart-rate. Bathroom scales such as Withings can not only track your weight but also measure fat and hydration. Your home WiFi system can also detect movement of people, making it an accessory for the safety of the elderly. Evaluating the quality of nutrition remains a difficult problem to solve for (as medical science has created contradictory guidance over the years, e.g. the earlier advice to avoid all fats, for example).
Measuring important vital signs is one part of staying healthy. The other determinant is based on genetics. Companies like 23andMe are bringing genetic insights (predisposition to various chronic conditions) to millions at low cost. 3D printing technology offers the possibility of tailoring medicines to take into account specific information (both environmental and genetic) about the patient to maximize the effectiveness of treatment. In 2015, Aprecia Pharmaceuticals received FDA approval for the first 3D printed drug (Spritam, used to treat epilepsy).
In 2008, Livongo was founded to deliver “connected glucose meters” to diabetics so that the company could intervene if customers’ blood sugar levels fail to stay within normal levels (or if patients neglect to take timely measurements). This is a costly issue for medical insurance companies: 10% of US adults are diabetic and failing to regulate blood-sugar can lead to catastrophic results including blindness, loss of limbs, and even death. Twelve years later, the small startup was acquired for $18.5B by Teladoc.
Another company, HaloDX is pursuing a similar model with “connected imaging machines”. Patients visit a local lab and their breast, prostrate, or lung images are automatically sent via a secure network to be analyzed by artifical intelligence (AI) applications that assist a central group of radiologists by highlighting potential tumors or issues. By “disaggregating” a traditional vertically-integrated diagnostic lab (where all the machines and people are physically in the same place), the company is able to provide higher-quality diagnostics at lower cost.
Another startup, Forward, is focused on using state-of-the-art laboratory tests to create “wellness plans” for its customers to keep them from getting ill or for helping to better keep their chronic conditions in check. Combined with a highly personalized customer-service model that includes online video consultations with their doctor on-demand, they are trying to make healthcare become a more enjoyable experience, leading to healthier customers. With better prevention, their customers can pay for Forward’s premium service by dropping their health insurance service tier (from Gold to Silver or Bronze) and accepting higher deductible costs.
Over 13 years ago, I was part of a group at Cisco that had imagined a future where the company’s new TelePresence video collaboration technology could be used to deliver remote patient diagnostics. The barriers to adoption back then were not technical, but regulatory and financial. Some US states did not allow a remote doctor to issue a prescription for a patient (or didn’t allow this across state lines). Insurance companies refused to create a reimbursement code that could be used to gain payment for a video-based consultation. These and other constraints have now been temporarily set aside during COVID-19 and healthcare companies have been allowed to use any number of “consumer-grade” technologies, such as Apple FaceTime and Zoom, to carry out consultations with patients. This has led to a boom in telemedicine consultations which have proved very popular with patients and doctors. It is likely that the relaxations in these regulatory constraints will be made permanent leading to the wider deployment of telemedicine solutions and further innovations in care-delivery.
Ultimately, we need to take an active role in becoming stewards of our wellness. Digital technologies like our phones, smart-watches, and home automation will help monitor and guide us to sustain healthy habits and detect when things start to go wrong. Genetic information and comprehensive lifestyle data will bring forward increasingly personalized medicine, where treatments are tailored for each individual. AI systems will increasingly detect and diagnose the onset of disease, augmenting the capabilities and accuracy of the doctors and nurses to create truly effective and affordable healthcare for all.
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Disclosure
I helped Nokia acquire Withings in 2016. I am also an investor in HaloDX
